Therapist information for inclusion in DBT directory

This survey is for currently listed therapists to renew their listing. If you are new to the directory, please do not complete the form below. Please go to this form instead. For those who are renewing, the only fields required on the form below are your name and the information about your DBT team. The other fields and information in the directory will be carried over from your submission last year. If something has changed please complete the appropriate fields so we can update the directory as needed. If you do not complete one of the optional fields, it will be assumed that that information remains current.

Personal and Practice Information

Your name as you want it to appear on the list *

Your name as you want it to appear on the list

First Name

Last Name

Credentials

Ph.D.

Ed.D.

Psy.D.

LCSW

LMFT

LPC

LPA

DBT Certification

DBT-Linehan Board of Certification, Certified Clinician

Other credential

Phone

Phone

What is your phone number?

(###)

###

####

Email Address

Location of Practice

Please select location(s) for your practice. If not listed, please select "Other" and fill in the location.

Cary

Chapel Hill/Carrboro

Durham

Hillsborough

Pittsboro

Raleigh

Other (please fill in below)

Other location

Please state the town or city if not listed above

Business Website

http://

Insurance (In-Network)

For which insurance panels are you in-network?

BCBS

United

Cigna

Medicaid

Medicare

Aetna

Medcost

Tricare

Magellan

Optum/United

Value Options

Other In-Network Plans

Do you submit out-of-network bills?

Yes

No

Training

Additional DBT training

What type of DBT training do you have?

2-day DBT Training

10-day DBT Intensive Training

Currently a member of a DBT Consultation/Training Team

Experience co-leading DBT Skills Groups

Trainer and location

If you have completed a 2 or 10 day training, who conducted and where was your training?

DBT Consultation Team or Training Team

DBT Consultation Teams are peer led, meet several times each month and are committed to practicing comprehensive DBT.
DBT Training Teams typically have an Intensively trained leader who may be paid, meet monthly and are committed to learning effective, comprehensive DBT.

Consultation team *

Do you participate on a regular DBT consultation team?

Yes

No

Training Team *

Do you participate on a DBT training team?

Yes

No

DBT Team Contact Name *

Please enter the name and email of your DBT team leader or contact.

Team Contact Email *

Number of team meetings per month

Year you first joined DBT team

DBT Services

Therapy Services *

When therapeutically indicated, what type of DBT services do you provide?